Cycle 1
Health 2025-03-07 · Fire 2025-03-07
8 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
16 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Carmel, IN
Retreat At The Stratford, The
3-star overall rating with 3-star inspections with 8 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
2460 Glebe St, Carmel, IN
(317) 733-9560
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
18
Certified beds
Average residents
10
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Senior Living Communities
Operator or chain grouping
Approved since
2012-01-04
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
9 facilities
Chain averages 4 overall / 4 health / 5 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.87
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
1.52
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
3.87
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
7.25
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
3.38
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
6.65
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
1.34
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.23
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.81
CMS adjusted RN staffing hours
Adjusted total hours
7.02
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
80%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
64%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,640
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
15.94
Composite VBP score used to determine payment impact.
Payment multiplier
0.9815
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.55% · Performance 22.77% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.43
Baseline 5.71% · Performance 7.41% · Measure score 1.43 · Achievement 1.43 · Improvement 0
Total nurse turnover
3.35
Performance 50.00% · Measure score 3.35 · Achievement 3.35 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.73% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 87 · Observed rate 9.2% · Lower 95% interval 7.31% |
| Discharge to community | 50.43% |
50.57%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 90 · Observed rate 47.78% · Lower 95% interval 42.58% |
| Medicare spending per beneficiary | 1.04 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 64 · Denominator 64 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 64 |
| Discharge self-care score | 48.98% |
53.69%
4.7 pts worse
|
Numerator 24 · Denominator 49 |
| Discharge mobility score | 14.29% |
50.94%
36.6 pts worse
|
Numerator 7 · Denominator 49 |
| Pressure ulcers or injuries, new or worsened | 4.69% |
2.29%
2.4 pts worse
|
Numerator 3 · Denominator 64 · Adjusted rate 4.37% |
| Healthcare-associated infections requiring hospitalization | 7.41% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 61 · Observed rate 6.56% · Lower 95% interval 3.76% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 71 |
| Staff flu vaccination coverage | 0.55% |
42%
41.5 pts worse
|
Numerator 1 · Denominator 182 |
| Discharge function score | 40.82% |
56.45%
15.6 pts worse
|
Numerator 20 · Denominator 49 |
| Transfer of health information to provider | 96.77% |
95.95%
0.8 pts better
|
Numerator 30 · Denominator 31 |
| Transfer of health information to patient | 96.43% |
96.28%
0.2 pts better
|
Numerator 27 · Denominator 28 |
| Resident COVID-19 vaccinations up to date | 29.03% |
25.2%
3.8 pts better
|
Numerator 9 · Denominator 31 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 72.7% |
93.6%
20.9 pts worse
|
93.4%
20.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 72.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.8%
3.8 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
24.6%
24.6 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.2%
1.2 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.7% |
24.2%
0.5 pts worse
|
19.8%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 24.7% |
| Percentage of long-stay residents with pressure ulcers | 1.7% |
4.1%
2.4 pts better
|
5.1%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 49.8% |
81.6%
31.8 pts worse
|
81.7%
31.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 48.1% · Q2 72.0% · Q3 54.9% · Q4 25.0% · 4Q avg 49.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.3% |
10.5%
5.2 pts better
|
12.0%
6.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.3% · Observed 5.0% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
1.3%
0.6 pts worse
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 2.6% · Q4 2.7% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.4% |
79.0%
3.4 pts better
|
79.7%
2.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 82.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.9% |
22.4%
3.5 pts worse
|
23.9%
2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.9% · Observed 21.7% · Expected 19.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-05 · Fire 2024-04-05
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-03-14 · Fire 2023-03-14
5 health deficiencies
Top issue: Resident Rights (2 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-17
F · Potential for more than minimal harm
2025-03-07
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2025-06-17
F · Potential for more than minimal harm
2025-03-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-17
F · Potential for more than minimal harm
2025-03-07
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2025-06-17
F · Potential for more than minimal harm
2025-03-07
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-06-17
F · Potential for more than minimal harm
2025-03-07
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-07-03
F · Potential for more than minimal harm
2025-03-07
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-07-03
F · Potential for more than minimal harm
2025-03-07
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-07-03
F · Potential for more than minimal harm
2025-03-07
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-06-17
E · Potential for more than minimal harm
2025-03-07
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-06-17
E · Potential for more than minimal harm
2025-03-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-06-17
E · Potential for more than minimal harm
2025-03-07
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-06-17
E · Potential for more than minimal harm
2025-03-07
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-06-17
C · Minimal harm
2025-03-07
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2025-06-17
C · Minimal harm
2025-03-07
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-06-17
C · Minimal harm
2025-03-07
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2025-06-17
F · Potential for more than minimal harm
2024-04-05
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-06-05
F · Potential for more than minimal harm
2024-04-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-05
F · Potential for more than minimal harm
2024-04-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-06-05
F · Potential for more than minimal harm
2024-04-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-05
D · Potential for more than minimal harm
2024-04-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-06-05
C · Minimal harm
2024-04-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-05
F · Potential for more than minimal harm
2023-03-14
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-07-03
F · Potential for more than minimal harm
2023-03-14
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-06-29
F · Potential for more than minimal harm
2023-03-14
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-06-29
F · Potential for more than minimal harm
2023-03-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-29
F · Potential for more than minimal harm
2023-03-14
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-06-29
F · Potential for more than minimal harm
2023-03-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-06-29
F · Potential for more than minimal harm
2023-03-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-03
E · Potential for more than minimal harm
2023-03-14
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-06-29
E · Potential for more than minimal harm
2023-03-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-06-29
E · Potential for more than minimal harm
2023-03-14
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-06-29
E · Potential for more than minimal harm
2023-03-14
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-06-29
E · Potential for more than minimal harm
2023-03-14
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-06-29
E · Potential for more than minimal harm
2023-03-14
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2023-06-29
C · Minimal harm
2023-03-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-06-29
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-02
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-06-16
D · Potential for more than minimal harm
2025-06-02
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-05-25
D · Potential for more than minimal harm
2025-03-07
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-04-02
D · Potential for more than minimal harm
2025-03-07
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-04-02
D · Potential for more than minimal harm
2025-03-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-02
D · Potential for more than minimal harm
2025-03-07
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-04-02
D · Potential for more than minimal harm
2025-03-07
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-04-02
D · Potential for more than minimal harm
2025-03-07
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-04-02
F · Potential for more than minimal harm
2024-04-05
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-05-15
D · Potential for more than minimal harm
2024-04-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-21
D · Potential for more than minimal harm
2024-04-05
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-05-15
F · Potential for more than minimal harm
2023-03-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-03-14
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-03-14
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-03-14
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-03-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-04-28
Penalties and ownership
What sits behind the stars
$0
2025-03-27
Payment Denial
Payment Denial · denial start 2025-06-27 · 6 days
6 day denial
Ownership
Thompson, Donald
5% Or Greater Direct Ownership Interest · Individual
Thompson, Benjamin
5% Or Greater Direct Ownership Interest · Individual
Thompson, Joshua
5% Or Greater Direct Ownership Interest · Individual
Maxwell Group, Inc.
Operational/Managerial Control · Organization
Miller, Bradley
Operational/Managerial Control · Individual
Solito, Leo
Operational/Managerial Control · Individual
Thompson, Benjamin
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Copper Trace Health & Living Community
Westfield, IN
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Majestic Care Of Carmel
Carmel, IN
3-star overall rating with 3-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Wellbrooke Of Carmel
Carmel, IN
3-star overall rating with 2-star inspections with $15,646 in total fines with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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